How to Start Billing CHI & PIN: Tools & Processes to Set Up First

Medicare started paying for community health integration (CHI) and principal illness navigation (PIN) in January 2024. Years later, there’s still a massive underutilization of these codes. This means organizations that could bill for these services are leaving money on the table. 

In 2024, there were only about 49,000 CHI and PIN service submissions across the entire country (41,362 for CHI and 7,934 for PIN), according to a JAMA Health Forum study of traditional Medicare claims. That's a tiny number next to the 34 million people in traditional Medicare, and the roughly 12.5 million people who are dually eligible for Medicare and Medicaid. Duals are the types of patients these codes were built for, since so many of them live with serious illness and unmet social needs at the same time.

But the services that did get billed didn't always get paid - 28.2% of CHI services submitted in 2024 were denied. The study's authors point to documentation requirements, staffing, and workflows that don't line up with how the services are delivered.

So the codes exist, and the patients exist. What's usually missing is the setup in between: who does the work, how eligibility gets documented, how time gets captured, and how a month of navigation turns into a well-documented claim.

This guide walks through that buildout one step at a time. If you've already read our post on how to track and document CHI and PIN services, consider this the groundwork that comes before it: the tools and processes to put in place before your team logs a single billable minute, plus the checks that keep claims eligible once you're up and running.

Quick note before reading: this guide is general information, not legal or billing advice. Check specific documentation questions with your compliance team or your Medicare Administrative Contractor.

CHI, PIN, and PIN-PS: a quick refresher

Quick Answer: CHI pays for help with unmet social needs that get in the way of a patient's care. PIN pays for help navigating a serious, high-risk illness, and PIN-PS is the peer support version for behavioral health conditions.

All three are Medicare care management services. That means the hands-on work is done by trained staff (called "auxiliary personnel" in Medicare terms) under the general supervision of a billing practitioner. General supervision simply means the practitioner directs the care and stays responsible for it, but doesn't need to be in the room while the work happens.

How CHI and PIN relate to each other (and to CCM)

The AAFP's PIN coding guide puts it well: CHI and PIN are very similar, but CHI is built around unmet social needs, while PIN is built around helping someone with a serious illness move through the health care system. A PIN patient might also have social needs, but they don't have to.

Chronic Care Management (CCM) is different. It's focused on the clinical side of care for patients with two or more chronic conditions. A single patient can qualify for CCM, CHI, and PIN at the same time, and all of them can be billed in the same month as long as the time and effort for each service is separate. We'll cover how to keep them separate in Step 7.

What changed in 2026

The 2026 Medicare Physician Fee Schedule made two updates worth knowing about, according to Becker's Hospital Review. CMS swapped CHI's "social determinants of health" language for the broader term "upstream drivers." It also clarified that clinical social workers, marriage and family therapists, and mental health counselors can bill directly for CHI and PIN when the services are tied to diagnosing or treating a mental illness.

Payment rates change every year and vary by location, so we've left specific dollar amounts out of this guide. You can look up current rates for your area with the CMS Physician Fee Schedule Look-Up Tool.

Step 1: Decide who does what before you start seeing patients

Quick Answer: Name your billing practitioners, the staff who'll deliver services, and how supervision works. If you're partnering with a community-based organization, get the contract and data-sharing pieces done first, since CBOs can't bill Medicare on their own.

CHI and PIN are team services, and Medicare is specific about each person's role. Sorting this out early saves you from issues down the road, like the wrong person doing the initiating visit or forgetting to collect a navigator's training records.

Pick your billing practitioners on purpose

The practitioner who does the initiating visit is the same one who bills for the patient's CHI or PIN services every month after that. That makes this a decision about specific people, not just your organization. Choose practitioners who have ongoing responsibility for the patient's care and who'll be available to review notes and approve monthly documentation.

Important note: emergency department providers can't act as the billing practitioner for ongoing CHI, according to Envision's CHW Financial Sustainability Toolkit. And individual CHWs can't submit claims to Medicare themselves.

Document training before staff start billing

If your state has CHW certification or training standards, follow them. If it doesn't, CMS requires auxiliary staff to be trained in a set of core skills, including patient and family communication, relationship building, care coordination and system navigation, patient advocacy, professionalism and ethics, and knowledge of local community resources. For PIN, staff also need training on the specific condition they're supporting. For PIN-PS, the AAFP notes that peer specialists should be trained in line with SAMHSA's National Model Standards for Peer Support Certification.

Keep a simple roster of every staff member delivering services, their training or certification, and the date it was completed. If an auditor asks who did the work and what qualified them, you'll have the answer in one place.

If you're working with a CBO, set up the partnership first

CBOs and community care hubs often have the staff and community relationships that make CHI and PIN work well. They can't bill Medicare directly, so the billing practitioner needs to contract with them. The Partnership to Align Social Care has resources for health care organizations contracting with CBOs, and Minnesota's health department publishes free CHI workflows and checklists for clinics, CBOs, and hubs.

Important note: the billing practitioner is responsible for all documentation, including notes written by contracted CBO staff. Your agreement should explain how CBO staff will log time, where their notes will live, and how your team will review them before billing. A shared, HIPAA-compliant care coordination platform that CBO staff can log into makes this much easier than emailing notes back and forth.

Step 2: Build a repeatable way to find eligible patients

Quick Answer: Screen for social needs with a standardized tool, flag patients with serious high-risk conditions, and use a few yes-or-no questions to sort each patient into CCM, CHI, PIN, or more than one.

Most practices already have CHI and PIN patients on their panel. Rachel Yates from Physicians Practice makes this point: these patients are often getting coordination help informally, and it's going unbilled. The goal of this step is to find them on purpose instead of by accident.

Screen for social needs with a standardized tool

A standardized screening tool gives your team a consistent way to spot social needs and a clear record of what you found. Two common options are the Accountable Health Communities HRSN Screening Tool developed by CMS and PRAPARE. Sending the screener as a digital intake form before the visit means the results are waiting when the practitioner walks in.

Important note: HCPCS code G0136 used to pay for a standalone SDOH risk assessment. In the 2026 fee schedule, CMS rewrote that code to cover a physical activity and nutrition assessment instead, according to First Coast Service Options, a Medicare Administrative Contractor. Screening still matters because it's how you find and document the need, just don't build your revenue plan around billing it as a separate code. It's also a good time to update your templates to CMS's newer "upstream drivers" language.

Sort patients with four questions

Once you know a patient's conditions and needs, these questions point you to the right service. Each one adapts the decision framework from the CMS rules for each code.

1. Does the patient have two or more chronic conditions expected to last at least 12 months? If yes, they may qualify for CCM.
2. Does the patient have an unmet social need (housing, food, transportation, utilities, or another upstream driver) that's getting in the way of diagnosing or treating a condition? If yes, they may qualify for CHI.
3. Does the patient have a serious, high-risk condition expected to last at least 3 months that puts them at risk of hospitalization, nursing home placement, sudden decline, or death? If yes, they may qualify for PIN. 
   
   1. A confirmed diagnosis isn't required. CMS says a suspected condition can qualify based on the practitioner's clinical judgment, as explained by AJMC.
4. Is that condition a serious mental illness or substance use disorder, and would a peer with lived experience be the best support? If yes, PIN-PS may be the better fit. 
   
   1. Remember PIN and PIN-PS can't be billed for the same condition.

A lot of patients will answer yes to more than one question. That's pretty common - we'll cover how to handle this in Steps 4 and 7.

Start with dual-eligible patients

If you're deciding where to begin, patients who have both Medicare and Medicaid are a natural first group. They tend to carry the heaviest mix of chronic illness and social need. Medicaid also generally covers their Medicare cost-sharing, so the 20% coinsurance is less likely to become a barrier to entry. Flag these patients in your patient tracking dashboard so your team can reach out to them first.

Step 3: Write an initiating visit note that holds up under audit

Quick Answer: A checkbox or one-line attestation isn't enough on its own. Use structured fields for codes and dates, and add a short, patient-specific explanation of the need or condition, how it affects care, and how CHI or PIN fits into the treatment plan.

Every CHI and PIN patient needs an initiating visit before services start. This is where the billing practitioner decides what services are medically necessary and sets up the plan the rest of the team will follow. It's also the note an auditor will likely review, so it's important to get this right the first time.

Which visits count as an initiating visit

That last visit type (inpatient, observation, emergency department, or skilled nursing facility visits) can cause confusion. Many hospitals and inpatient facilities screen for social needs at admission, but finding a need during an inpatient stay doesn't count towards CHI or PIN. The patient needs a separate outpatient visit after discharge, and a TCM visit is often the most natural fit.

Is a checkbox or attestation enough?

Short answer: no, not by itself. CMS doesn't ban templates, but its Medicare Program Integrity Manual (Chapter 3) discourages templates that rely on checkboxes, predefined answers, or very limited space. CMS says claim reviews have shown these templates often don't capture enough detail to prove coverage and coding requirements were met. It also warns that templates built mainly for billing tend to fall short on showing medical necessity.

The CHI rule itself makes this even clearer. The practitioner has to identify the specific social needs that significantly limit their ability to diagnose or treat the patient, and explain how addressing those needs would support the treatment plan. It’s hard to fully describe those things using checkboxes or predefined answers alone. 

The practical answer is to use both. Structured fields keep codes, dates, and consent consistent and easy to report on. A few sentences of free text, written by the practitioner about this specific patient, shows why the service is needed. That satisfies the information auditors are looking for: the link between the need and the care.

What the initiating visit note should include

For CHI:

• The condition(s) addressed at the visit, with ICD-10 codes
• The specific unmet social needs, coded with Z-codes (Z55 to Z65) when they apply
• How each need limits your ability to diagnose or treat the condition (the "because" sentence)
• The treatment plan and how CHI services will help carry it out
• Your decision that CHI is medically necessary, and that trained staff will provide the services under your general supervision
• The needs added to the problem list
• For an Annual Wellness Visit, a note that the unmet need is keeping the patient's personalized prevention plan from being carried out, according to NACHC

For PIN, swap the social need for the serious, high-risk condition. Document that it's expected to last at least 3 months, what it puts the patient at risk for (hospitalization, nursing home placement, sudden decline, or death), and why the patient needs navigation help. 

The AAFP adds that a qualifying condition usually calls for a disease-specific care plan that gets built, monitored, or revised over time. A suspected condition can qualify, so you don't need to wait for a confirmed diagnosis.

Here's what a solid CHI narrative might look like

Ms. R, 72, has type 2 diabetes with hyperglycemia (E11.65) and an A1C of 9.4. She reports skipping insulin near the end of each month because she can't afford both food and medication, and she's missed two of her last three appointments because she no longer has reliable transportation since her husband passed. Food insecurity (Z59.41) and transportation insecurity (Z59.82) are significantly limiting my ability to treat her diabetes, since I can't safely adjust her insulin while her meals and doses are inconsistent. Plan: begin CHI services. A CHW will help her apply for SNAP and a meal delivery program, set up rides to appointments, and check in weekly on medication use. Goal is consistent insulin use and an A1C under 8 within six months. Discussed CHI with the patient, including the 20% coinsurance and that only one practitioner can bill CHI each month. Verbal consent given.

It's one short paragraph, and an auditor can follow the whole story: the condition, the need, why the need matters clinically, the plan, the goal, and consent.

Build the template so it supports good notes

Your initiating visit template might live in your EHR or form builder. Either way, set up required fields for the codes, visit date, and billing practitioner. Then add a required free-text box for the "why the need matters" statement the practitioner needs to explain. 

If the visit is documented in an EHR, connect it to your care management platform (and vice versa). That way the visit date, practitioner, and qualifying needs carry over automatically when the patient is enrolled, so your team doesn't have to retype them.

Step 4: Treat consent as a workflow, not a one-time action

Quick Answer: Get consent before services start, explain cost-sharing and the one-practitioner rule, document it in the record, and track when it needs renewing. CHI consent generally lasts until the billing practitioner changes, while PIN consent should be renewed every year.

Consent sounds straightforward, but small mistakes can make the entire claim fall apart. If the consent date is missing, comes after the first billed minute, or belongs to a different practitioner, the whole month is put at risk.

The basics

• Who can collect consent: The billing practitioner, or auxiliary staff working under general supervision, according to NACHC.
• Format: Verbal or written. Both are fine as long as it's documented in the medical record.
• Timing: Before services begin. Time logged before consent shouldn't count toward billing.

What to explain to the patient

Patients deserve to understand what they're agreeing to, and Medicare requires a few specific points to be explained. Cover these in plain language:

• What the service is and who'll be reaching out to them
• That Medicare Part B cost-sharing applies (the deductible and 20% coinsurance). Supplemental coverage like Medigap may pick this up, and for dual-eligible patients, Medicaid generally covers it.
• That only one practitioner can bill CHI for them each month, and PIN can only be billed once a month per condition by the same practitioner

You also can't waive the coinsurance as a courtesy, as Envision's toolkit points out. Federally qualified health centers can apply their sliding fee discount policy, according to NACHC.

Developing a short script can help staff stay consistent with how they communicate this information to patients:

"Dr. Patel would like a community health worker on our team to help you with transportation and food resources so you can stay on track with your diabetes care. They'll check in with you by phone and text throughout the month. Medicare covers this, but like other Part B services, there's a 20% coinsurance, which your Medicaid coverage usually pays. Only one practice can bill for this service each month. Is it okay if we get started?"

Know when consent needs renewing

The guidance isn't identical for every service, so it’s beneficial to track them separately:

If a patient may need more than one service

Get a separate consent for each service. When patients qualify for more than one service, providers usually collect consent for every service that might apply at the start. That way they don’t have to chase down the patient for another signature later. Then they bill based on the care actually delivered that month.

The tools that make this easy

• A consent form that supports e-signatures, plus a quick way to record verbal consent (who obtained it, when, and what was explained)
• A consent date stored on the patient record for each program, so billing teams can easily check it
• Automatic reminders before PIN consent expires, set up through workflow automation
• A rule that flags any time logged before the consent date, so it doesn't end up on a claim

Step 5: Set up programs, billing codes, and automatic time capture

Quick Answer: Create a separate program for each service, tied to its first-60-minutes code and add-on code. Then capture time automatically as staff work, so small tasks across the month add up without anyone having to rebuild them later.

CHI and PIN are paid by the month, based on the total time trained staff spend on a patient's behalf. Once a patient hits 60 minutes in a calendar month, you can bill the base code. Each additional 30 minutes can be billed as an add-on, and the Partnership to Align Social Care notes there's no monthly cap as long as the services are medically necessary and documented. 

That setup rewards teams that capture every minute, including small actions that are easy to forget like a ten-minute phone call.

Important note: check with your Medicare Administrative Contractor on how partial add-on blocks are counted.

Set up one program per service

Build each service as its own program in your care management platform, with its codes and monthly threshold attached:

Keep PIN and PIN-PS as separate programs, since they have different service elements and can't be billed for the same condition. If a patient has PIN for more than one serious condition, track each condition separately too. The APA notes PIN can only be billed once per month per condition by the same practitioner.

Capture time as the work happens

Asking staff to remember billable time at the end of the day (or worse, the end of the month) is how minutes get lost. A better approach is to start timers automatically in your care management platform when patient work happens. In Tellescope, for example, time tracking can start when a staff member:

• Opens a patient's chart
• Completes a phone or video call
• Sends a message
• Completes a form linked to the program

Staff also need a manual option. They might log a visit to a food pantry with the patient, pick up a paused session, or move an entry to the right patient or program. Auto-captured time should still be reviewed - opening a chart only counts if the staff member was actually doing work for the patient, like reviewing records to coordinate care.

What counts as billable time

Time doesn't need to be face to face. NACHC notes that CHI is mostly made up of non-face-to-face work. That includes messages, phone calls, reviewing records, coordinating with other providers, and connecting patients to community resources. Calling a landlord or utility company on a patient's behalf counts too, as long as it ties back to the care plan.

The channel you use doesn't change how you bill. As AJMC notes, CHI and PIN aren't on Medicare's telehealth list because they aren't meant to replace an in-person visit. You can still deliver them by phone, video, text, or portal message, without telehealth modifiers (like -93 or -95) or originating site rules.

Here's how a month adds up

This example builds on a congestive heart failure case from the APA. John, 65, was recently diagnosed with CHF. He's overwhelmed by his treatment plan, struggles to take his medications, and doesn't have reliable transportation. After his initiating visit, his patient navigator logs the following during the month:

None of these tasks would show up on a claim on its own. Together, they reach the 60-minute threshold for G0023. If the navigator had logged another 30 minutes that month, the practice could also bill one unit of G0024.

Step 6: Document each activity so it ties back to eligibility

Quick Answer: Every time entry should say who did the work, what they did, how long it took, and how it connects to the need or condition from the initiating visit. Build that into your templates so staff don't have to remember to document that each time.

CHI and PIN target different things. CHI is about unmet social needs, and PIN is about navigating a serious illness. Your documentation has to show the work matched the reason the patient qualified. The AAFP says PIN notes should include the time spent, the type of activity, and how each activity relates to the treatment plan, along with any social needs addressed. CMS encourages using Z-codes when they apply.

The easiest way to make this consistent is to split documentation into two layers.

Layer 1: Patient-level details (captured once, included in every entry)

• The program (CHI, PIN, or PIN-PS) and, for PIN, the specific condition
• The qualifying need or condition, with ICD-10 and Z-codes
• The initiating visit date and billing practitioner
• The consent date and how consent was given
• The care plan goals

When these are located in the patient's record, every time entry inherits them automatically, staff don't need to retype them, and billing teams can see them at a glance.

Layer 2: Activity-level details (captured each time)

• Date and the staff member who did the work
• Time spent
• Activity type, picked from a list that mirrors CMS's service elements: person-centered assessment, care coordination, health education, building self-advocacy skills, health system navigation, help accessing community services, behavior change support, and social and emotional support
• A sentence or two connecting the activity to the plan
• Any new needs that came up

Important note regarding this last bullet point: NACHC notes auxiliary staff should pass newly identified needs to the billing practitioner, who decides whether to add them to the treatment plan. Build a simple flag or task that routes those to the practitioner, so the plan stays current.

A weak entry vs. a strong one

The strong entry doesn't take much longer to write, and it answers every question a reviewer would ask.

If a CBO partner is doing the work

The billing practitioner is responsible for all documentation, including notes written by contracted CBO staff, according to NACHC. The ideal setup gives CBO staff access to the same templates in a shared platform, limited to the patients they serve. That way their entries follow the same structure as yours and sync back to the patient’s record. It's a lot easier than reconciling spreadsheets or emails at the end of the month.

Step 7: Build in checks for concurrent billing

Quick Answer: CHI and PIN can be billed in the same month as CCM and other care management services, as long as each minute is only counted once. Put automatic checks in place so the same work never shows up in two claims.

Many of your CHI and PIN patients will also be enrolled in other programs, like CCM, Principal Care Management (PCM), Transitional Care Management (TCM), or remote patient monitoring. Medicare allows that: NACHC lists CCM, PCM, TCM, PIN, behavioral health integration, collaborative care, RPM, remote therapeutic monitoring, and Advanced Primary Care Management as services that can be billed alongside CHI. Each service still needs its own consent, cost-sharing, and time that isn't already counted in a different claim.

Guidelines to follow

• No double-counted time: a minute logged to CHI can't also count toward CCM, according to AAFP.
• One practitioner per service per month: only one practitioner can bill CHI for a patient each month.
• One PIN per condition: the same practitioner can only bill PIN once a month for a given condition. PIN and PIN-PS can't both be billed for the same condition. A patient can get more than one PIN service if each one covers a different condition or comes from a different practitioner, according to APA Services.
• Clinical work belongs to clinical codes: medication changes and side effect management can come up during navigation. AJMC notes those are better captured under services like PCM.
• FQHC note: NACHC says FQHC practitioners can't bill CHI while the patient is receiving Medicare home health services.

Checks your platform should run

What this looks like in practice

Say a patient is enrolled in both CCM and CHI. On Tuesday, a nurse calls to adjust her blood pressure medication, then hands the call to a CHW who sets up rides to her next two appointments. That's two entries: the nurse's time goes to CCM, and the CHW's time goes to CHI. If the nurse also mentioned the transportation problem in passing, that doesn't make it CHI time. Each person logs only the work they did, under the program it supports.

Step 8: Run a month-end close (and start it before the month ends)

Quick Answer: Track threshold progress during the month, get documentation approved by the billing practitioner before the month closes, choose the right codes and units, and send that data to billing. FQHCs and RHCs follow a few extra rules.

Because CHI and PIN are billed by calendar month, the end of the month is the deadline. A patient sitting at 52 minutes on the 31st doesn't get billed, and those minutes don't roll over.

Watch threshold progress all month

Don't wait until the last few days to see where patients are at time-wise. Set up a view or alert that shows patients who are close to the 60-minute mark, already past it, or falling behind. A mid-month check around day 15, plus another a week later, gives staff time to reach out to patients who still need support. You can learn more about this in our CHI and PIN tracking guide.

Route documentation for approval

The billing practitioner should review each patient's monthly documentation before it goes to billing. A simple status path keeps everyone on the same page: 

• Pending: work logged, waiting for review
• Approved: practitioner signed off
• Billed: claim submitted

The practitioner can approve, comment, or send entries back for more detail without anyone digging through a separate inbox.

Choose codes, units, and the date of service

• Pick the service(s): for patients who consented to more than one service, review what was actually delivered and bill accordingly. That's the approach described in AJMC.
• Count units: one base code for the first 60 minutes, plus one add-on for each additional 30 minutes.
• Set the date of service: NACHC says it can be the date billing requirements were met or any later date in the same calendar month.
• Include the right diagnoses: Carry over the ICD-10 and Z-codes from the initiating visit.

Extra rules for FQHCs and RHCs

Since January 2025, FQHCs and RHCs must bill CHI, PIN, and PIN-PS with their individual codes instead of the old bundled care management code (G0511). These services are paid at the national rate, outside the FQHC prospective payment system (PPS) or the RHC all-inclusive rate. They aren't adjusted for location either, according to the Partnership to Align Social Care. The initiating visit is still paid separately under PPS or the all-inclusive rate. NACHC adds that a PPS visit and a care management service can go on the same Medicare claim.

Other practices are paid under the Physician Fee Schedule, which varies by location. Use the CMS Look-Up Tool to check your rates.

Optimize the handoff workflow to billing

The smoother the handoff, the fewer denials you'll see. Approved items should flow into your EHR or billing system with the patient, codes, units, date of service, billing practitioner, and diagnoses already attached. Tellescope connects with EHRs like athenahealth, Elation Health, Canvas Medical, Healthie, Medplum, and DrChrono through its EHR integrations, so approved work doesn't need to be retyped.

It also helps to verify coverage before you bill. The AAFP notes that most Medicare Advantage plans cover PIN, while commercial coverage varies. Partners like SuperDial can automate insurance verification calls from inside Tellescope.

Learn from denials

In the JAMA Health Forum study, 28.2% of submitted CHI services were denied in 2024. Track every denial reason, then tighten the template, consent step, or check that would have caught the mistake.

Month-end checklist

• Every billed patient has a documented initiating visit by the billing practitioner
• Consent is on file and dated before the first billed minute
• Time totals meet the 60-minute threshold, and add-on units match the extra time
• No minutes are counted under more than one program
• The billing practitioner has approved the month's documentation
• Codes, units, diagnoses, and date of service are entered correctly
• Coverage and secondary insurance are verified
• Items are marked as billed once claims go out

Step 9: Track time by funding source and use it to prove value

Quick Answer: If your CHWs or navigators are also funded by grants, tag each time entry by funding source so Medicare and grant dollars are kept separate. That same data shows leadership and funders what the program is worth.

Many CHW and navigation programs start out on grants. Medicare billing doesn't have to replace that funding, but it does mean you need to show which dollars paid for which work. Envision's CHW Financial Sustainability Toolkit calls this "braided funding." It's when several funding streams support one program, but each keeps its own rules and reporting. The toolkit says braided funding only works if you can track staff time and activities separately for each source.

Their example is an FQHC that bills Medicare CHI for its Medicare patients and Medicaid for eligible Medicaid patients. It also uses a foundation grant to support migrant workers who aren't covered by either. By matching each patient to the right funding source, the FQHC turns those streams into steady funding for its CHW positions.

What to set up

• A funding source field on every time entry or program enrollment (Medicare CHI, Medicaid, a specific grant, and so on)
• Reports that total hours by funding source, so grant reports and Medicare claims never overlap
• A plan for grant dollars to cover people Medicare doesn't, like uninsured patients or people who need support before they qualify

Measure what leadership cares about

The same data can help build the case for growing your program. In the Envision toolkit, Prisma Health used its EHR to track its CHW program's impact. The results showed fewer preventable ED visits and a clear return on investment, which helped move those CHW roles from grant funding into the health system's operating budget.

Here are some metrics you can track to help prove your ROI:

• Percent of enrolled patients who reach the 60-minute threshold each month
• Billed and paid services per CHW or navigator
• Denial rate and top denial reasons
• Patient outcomes tied to the care plan, like kept appointments, medication adherence, or ED visits

Your CHI and PIN setup at a glance

Quick Answer: Before you bill, you'll want nine pieces in place. They cover people and partnerships, patient identification, documentation, consent, time capture, duplicate checks, month-end review, and funding tracking.

How Tellescope supports CHI and PIN programs

Quick Answer: Tellescope brings program setup, time capture, documentation, approvals, and threshold tracking into one HIPAA-compliant platform. It connects to 6+ EHRs, so your team isn't jumping between tools.

The policy side of CHI and PIN is the same for everyone. Where organizations differ is how much manual work it takes to follow it every month. Tellescope is built to take the busywork out of the steps above:

• Programs tied to billing codes: you can configure CHI, PIN, and PIN-PS programs with their base and add-on codes and monthly thresholds.
• Automatic and manual time tracking: timers can start when staff open a chart, finish a call or video visit, send a message, or complete a program form. Staff can also log, pause, or reassign time by hand.
• Session documentation: each time entry is tied to the right patient and program, along with the activity, notes, forms, and call details.
• Forms and consent: Tellescope’s HIPAA-compliant form builder handles screeners, consent forms, and recurring documentation.
• Approval routing: monthly documentation goes to the initiating practitioner, who can review, comment, and approve. Items move from Pending to Approved to Billed.
• Threshold visibility: alerts and views show which patients are close to, over, or at risk of missing the monthly minimum.
• Outreach on every channel: staff can reach patients by SMS, email, phone, video, and chat from one inbox, and that work counts towards billable time.
• EHR connections: Tellescope works alongside your EHR, not as a replacement. Most practices keep their official clinical record and submit claims through an EHR certified by the ONC Health IT Certification Program. That certification supports CMS programs like Promoting Interoperability, so the initiating visit, final documentation, and claims usually stay in the EHR. Tellescope’s native integrations with athenahealth, Elation Health, Canvas Medical, Healthie, Medplum, and DrChrono, plus third-party integrations through Keragon, keep initiating visit details, approved time, and billing data in sync across both systems. 

If you're building a program with CBO partners, the same platform can give their staff a shared place to log time and document work. That way everything lands in one record your billing practitioner can utilize.

Final takeaway

A note on compliance: Monthly care management codes like CHI, PIN, and CCM can draw close scrutiny from CMS. The best protection is documentation that’s audit-ready from day one. That covers medical necessity, consent, supervision, time logs, patient cost-sharing, and accurate billing. This guide is for education only and isn’t billing, legal, or compliance advice. Before you launch or expand a CHI or PIN program, review your workflows with a Medicare billing expert and your compliance or legal team.

CHI and PIN pay for work certain care teams already do every day: helping a patient coordinate a ride to dialysis, helping someone apply for food assistance, or walking a newly diagnosed patient through their care plan. The 2024 stats show most of that work still isn't getting billed, and when it is, a large portion gets denied due to workflow mishaps.

Most of the fix happens in operations. If you decide roles up front, write initiating visit notes that tell the patient's story, treat consent as an ongoing process, and capture time as it happens, these services can support your staff instead of adding to their workload. Add duplicate checks and a month-end review that starts before the month ends, and the billing will follow.

If you’re building or growing a CHI or PIN program, book a demo with Tellescope to see how billing-ready workflows, time tracking, documentation, and approvals work together in one place.